Correct Answer: C

Rationale: Children with ADHD often display hyperactive and impulsive behaviors, such as excessive running, climbing, and fidgeting. These behaviors are characteristic symptoms of the hyperactive-impulsive subtype of ADHD. Children with ADHD may struggle to sit still, have difficulty engaging in quiet activities, and often seem on the go. Therefore, the nurse would expect to see signs of excessive movement and restlessness in a child with ADHD.

Correct Answer: D

Rationale: When a woman in active labor demonstrates signs of cephalopelvic disproportion (CPD) with the fetal head failing to descend despite strong contractions, the nursing action that should be prioritized is to prepare for immediate instrumental delivery. CPD can lead to a prolonged and difficult labor, increasing the risks for both the mother and the fetus. In cases where the fetal head is not descending adequately and the mother's contractions are strong, instrumental delivery, like forceps or vacuum extraction, may be necessary to facilitate the safe delivery of the baby. It is important to act promptly to avoid potential complications associated with prolonged labor. Other actions, such as performing a pelvic exam, changing maternal positions, or administering oxytocin, may be considered but addressing the issue of CPD efficiently through instrumental delivery should take precedence in this scenario.

Correct Answer: A

Rationale: The presentation of sudden-onset unilateral facial droop, arm weakness, and slurred speech that partially resolved within 30 minutes is more consistent with a transient ischemic attack (TIA) rather than an ischemic or hemorrhagic stroke. TIAs are caused by temporary decreases in blood flow to a specific area of the brain, leading to transient neurological deficits that typically last for less than 24 hours. In this case, the symptoms partially resolving suggest a temporary and reversible ischemic event, characteristic of a TIA. Ischemic strokes involve more prolonged or permanent impairment due to blockage of a blood vessel supplying the brain, while hemorrhagic strokes involve bleeding within the brain tissue or the surrounding membranes.

Correct Answer: A

Rationale: The presentation described is consistent with anterior uveitis. Anterior uveitis involves inflammation of the iris and ciliary body. Patients typically present with symptoms such as redness, pain, photophobia, and blurred vision. The slit-lamp examination findings of ciliary injection (redness and dilation of blood vessels in the iris and ciliary body), corneal edema, and a mid-dilated pupil with a fixed reaction to light (due to ciliary muscle spasm causing decreased accommodation) are characteristic of anterior uveitis. This condition is often idiopathic but can be associated with various systemic diseases like ankylosing spondylitis, inflammatory bowel disease, and other autoimmune disorders. Treatment involves addressing the inflammation with topical corticosteroids and, in some cases, cycloplegic agents to reduce pain and inflammation.

Correct Answer: A

Rationale: The first responsibility of a nurse when a patient falls is to assess the patient's injury. Assessing the patient's injury immediately allows the nurse to determine the severity of the fall and provide appropriate care and interventions. It is important to assess for any signs of injury, such as pain, swelling, bruising, or altered mobility, and to address any immediate medical needs. Once the patient's injury has been assessed, the nurse can then proceed to report the incident to the head nurse, write an incident report, and notify the physician if necessary.